<div class="form_container">
	<div class="field-row">
	    <div class="field-label">{translate}Grand total{/translate}</div>
	    <div class="field-value" style="width: 140px; text-align: right;"><span class="field"  id="totalPatientPrice">{$grandTotal}</span></div>
	    <div style="clear: both;"></div>
	</div>
	<div class="field-row">
	    <div class="field-label">
	        {translate}Advance payment{/translate}
	    </div> 
	    <div class="field-value" style="width: 140px; text-align: right;">	        
	            <span class="field">{$realPayment}</span>
	    </div>
	    <div style="clear: both;"></div>
	</div>
	<div class="field-row">
	    <div class="field-label">{translate}Patient's debt{/translate}</div>
	    <div class="field-value" style="width: 140px; text-align: right;"><span class="field">{$remainingAmount}</span></div>        
	    <div style="clear: both;"></div>
	</div>
</div>